Small Cell Neuroendocrine Carcinoma in Head and Neck

Introduction: Poorly differentiated neuroendocrine carcinomas (NECs) originating from the eye are rare and very highly malignant diseases with a poor prognosis. Small cell NEC of the head and neck is a rare disease and highly aggressive. Early recognition and treatment are crucial for reducing morbidity and mortality. Case Presentation: A 19-year-old male visited our oncology surgery outpatient department due to the progressive neck mass enlargement originating from the eye. The patient was previously diagnosed with invasive choroid malignant melanoma of the left eye which had metastasized to the lymph nodes of the left neck. He underwent a surgical removal/exenteration of the left eye. The result showed that the patient’s survival with poorly differentiated tumors was about 14% while patients with well-differentiated NEC had a survival rate of 34%. It also indicates that the prognosis of these tumors is very poor with a total of over 90% of patients having distant metastatic disease. Histopathological examination showed the tumor tissue and its immunohistochemistry with positive streaks of CD56, NSE, Synaptophysin, and Ki67 suggested small cell NEC.Conclusions: it is crucial to establish an early diagnosis of these tumors to reduce morbidity and mortality. No optimal treatment for such disease has yet been established.

Anticoagulation may contribute to antimicrobial treatment of Lemierre syndrome: a case report

Background Lemierre syndrome (LS) is characterized by multisystemic infection beginning in the oropharynx, local thrombophlebitis (typically, of the internal jugular vein) and peripheral embolism. No evidence-based guidelines exist for the management of this disease, and the use of anticoagulation therapy remains particularly controversial. Case presentation A 61-year-old man presenting with left neck swelling, odynophagia, and dyspnea underwent emergency surgery and received intravenous antibiotics. The primary infection was controlled on hospital day 5, but on day 6 sudden leukocytosis and hypoxemia were observed. CT angiography revealed an intraluminal filling defect in the pulmonary artery on day 8. LS was diagnosed and anticoagulation therapy was initiated. The WBC count, which had maintained its peak values in the previous 2 days, decreased instantly after initiation, and follow-up controls showed thrombus resolution. Conclusions Our case supports the notion that anticoagulation therapy may be a valid supplement to antimicrobial therapy in LS, especially in the presence of a possibly young thrombus as suggested by clinical worsening.

An aggressive case of Warthin-like variant of papillary thyroid carcinoma (PTC)

Introduction/Objective Warthin-like variant of PTC is a rare subtype of PTC, characterized by papillary growth lined with oncocytic neoplastic cells and lymphocytic rich stroma in the stalks of the papillae. It is frequently associated with Hashimoto thyroiditis and has good prognosis due to lower risk of metastasis. An association with BRAF V600E mutation has been reported. Here we report an aggressive case of Warthin-like variant of PTC. Methods/Case Report A 33-year-old Hispanic female presented with a progressively expanding neck mass, difficulty swallowing, voice hoarseness, and neck pain. Ultrasound showed a 3.8 cm left thyroid nodule which on biopsy was positive for PTC. Laboratory tests were positive for anti-peroxidase and anti-thyroglobulin antibodies. A total thyroidectomy was performed. Grossly, the left thyroid lobe nodule was well-circumscribed, unencapsulated, and firm with solid homogenous gray-tan cut surface. Microscopically, the nodule consisted of large eosinophilic cells demonstrating characteristic PTC nuclear features, arranged in papillary structures with the cores packed with prominent lymphoplasmacytic infiltrate consistent with Warthin-like variant of PTC (figure). Separate sub-centimeter foci of PTC with similar features were identified in a background of chronic lymphocytic thyroiditis. Central and left neck dissection showed extensive lymph node metastasis which had features similar to the primary tumor but with less pronounced lymphoplasmacytic cores. The patient is currently 6-month post operation and is receiving iodine ablative therapy. Results (if a Case Study enter NA) NA Conclusion Molecular analysis of the tumor may aid in identifying molecular aberrations responsible for the aggressive nature in this case and potentially guide treatment.

MRI findings seen in serous atrophy of bone marrow

An 85-year-old man was referred for an MRI scan of the pelvis for further evaluation of a suspected left neck of femur fracture, which was regarded as equivocal on plain radiograph and CT. The initial MRI demonstrated unusual appearances of the visualised bone marrow and subcutaneous adipose tissue and was initially misinterpreted as a technical malfunction of the scanner. However, a repeat study on a different scanner the following day once again demonstrated the same appearances. The appearances were consistent with serous atrophy of bone marrow, a non-neoplastic disorder of the bone marrow, which is most commonly seen in severe anorexia nervosa or cachexia. These unusual, but distinct, bone marrow and subcutaneous adipose tissue appearances, which are specific to MRI, have been colloquially termed as the ‘flip-flop’ effect.

A Challenging and Rare Case of Metastatic Follicular Dendritic Cell Sarcoma Originating from a Tonsil

Introduction/Objective Follicular dendritic cell sarcoma (FDCS) is a rare malignant tumor of follicular dendritic cells. Most cases of FDCS are described in lymph nodes, but it can involve extra-nodal locations such as the tonsil. Methods/Case Report We report a case of a 55-year-old male with a 6-month history of a slow growing left neck mass. The patient had a poorly differentiated carcinoma of the left tonsil diagnosed based on morphologic features eight years ago, followed by chemoradiation, and subsequent left tonsillectomy without tumor identified. Imaging reported a 4.0 cm mass in the left neck level III lymph node location. Biopsy of the mass revealed a spindle cell neoplasm. It was difficult to reach a definitive diagnosis despite an extensive work-up. Review of the previous left tonsil biopsy showed a pleomorphic epithelioid cell proliferation. On the radical resection specimen of the left neck mass, a 4.5 cm, tan-gray, fleshy, necrotic mass was present. Microscopically, it demonstrated a neoplasm with spindle cell and epithelioid cell proliferation, with extensive necrosis. A wide panel of immunostains was performed; the tumor cells showed positivity for CD21, CD23, CD35, and focally weak positivity for cytokeratin OSCAR and Synaptophysin. Squamous cell markers were negative. These findings are consistent with FDCS. Further work-up on the original tonsil tumor displayed immunostaining profile of FDCS. This case was consulted with the National Institute of Health (NIH) for confirmation of the diagnosis. Results (if a Case Study enter NA) NA Conclusion Morphologically, FDCS can present with various histologic patterns, which can lead to diagnostic pitfalls, and common confusion with poorly differentiated carcinoma or soft tissue tumors, especially in needle biopsies. Generally, patients present with a prolonged clinical course, with a 50% and 25% chance of recurrence and metastasis respectively, hence the awareness and accurate diagnosis of this entity is important in biopsies of lymph nodes or of extranodal locations such as a tonsil.

Anticoagulation May Contribute to Antimicrobial Treatment of Lemierre Syndrome: A Case Report

Background: Lemierre syndrome (LS) is characterized by multisystemic infection beginning in the oropharynx, local thrombophlebitis (typically, of the internal jugular vein) and peripheral embolism. No evidence-based guidelines exist for the management of this disease, and the use of anticoagulation therapy remains particularly controversial. Case presentation: A 61-year-old man presenting with left neck swelling, odynophagia, and dyspnea underwent emergency surgery and received intravenous antibiotics. The primary infection was controlled on hospital day 5, but on day 6 sudden leukocytosis and hypoxemia were observed. CT angiography revealed an intraluminal filling defect in the pulmonary artery on day 8. LS was diagnosed and anticoagulation therapy was initiated. The WBC count, which had maintained its peak values in the previous two days, decreased instantly after initiation, and follow-up controls showed thrombus resolution. Conclusions: Our case supports the notion that anticoagulation therapy may be a valid supplement to antimicrobial therapy in LS, especially in the presence of a possibly young thrombus as suggested by clinical worsening.

270 LYMPHADENECTOMY ALONG BILATERAL RECURRENT LARYNGEAL NERVE UNDER SINGLE-PORT INFLATABLE MEDIASTINOSCOPY THROUGH LEFT NECK APPROACH

Mediastinal lymphadenectomy is a crucial part of minimally invasive esophagectomy, and requires transthoracic operation, which is a crucial independent risk factor for the incidence of pulmonary complications. Conventionally, non-transthoracic esophagectomy was often achieved by mediastinoscope-assisted laparoscopic transhiatal surgery. Because of the small space, the lymphadenectomy could be only performed partially under mediastinoscope in upper mediastinal. We propose a new approach of lymphadenectomy along bilateral recurrent laryngeal nerve under mediastinoscopy through one left-neck incision. Methods A 3-cm incision paralleling the clavicle was made at 2-cm from the supraclavicular region in the left neck. After established pneumomediastinum (10-12 mmHg carbon dioxide), esophagectomy begins to perform over the aortic arch to the level of lower edge of the left main bronchus, and the lymphadenectomy along the left RLN has also accomplished during this process. At the level of lower edge of the right subclavian artery (RSA), between the trachea and the esophagus, the instruments could get accessed to the right RLN. The lymphadenectomy could get accomplished up to 2-cm at the upper edge of the RSA. Results The mean age of 56 esophageal squamous cell cancer patients was 67.4 years, 46 males and 10 females. Tumor location: middle thoracic, 31 patients, lower thoracic, 23 patients. Preoperative TNM staging: T1b was 10 cases, T2 was 35 cases, and T3 was 11 cases. The median number of mediastinal LNs removed was 17 (9 to 23); 6 (2 to 9) along the left RLN; 3 (1 to 6) along the right RLN. 7 patients (12.5%) developed RLN palsy. Postoperative laryngoscopy showed that all of the 7 RLN palsy were left side, none of them appeared at 3 months postoperation. Conclusion This approach enables the lymphadenectomy along bilateral RLN through one left neck incision. During the operation, the upper mediastinal LNs along the bilateral RLN were clearly revealed and en bloc excised. Meanwhile, the bilateral RLN were fully exposed and protected during the procedure. Compared with the previous surgical methods,this procedure is less invasive, and the bilateral RLN could be exposed much clearer. It would provide a novel approach for the minimally invasive esophagectomy, especially lymphadenectomy.

770 CONSIDERABLE EFFECT OF UPPER MEDIASTINAL LYMPHADENECTOMY UNDER LAPAROSCOPIC ASSISTED SINGLE-PORT INFLATABLE MEDIASTINOSCOPY THROUGH LEFT NECK APPROACH

Conventional minimally invasive esophagectomy requires transthoracic surgery, which could increase the risk of many perioperative complications. Mediastinoscopy-assisted transhiatal esophagectomy has been proposed for years, but the traditional methods have shortcomings, such as unclear vision, especially during the dissection of upper mediastinal lymph nodes. We proposed a novel approach of upper mediastinal lymphadenectomy with mediastinoscopy through a left-neck incision, and investigated the effect of lymphadenectomy and other perioperative outcomes. Methods This approach for upper mediastinal lymphadenectomy includes three parts. (I) Lymphadenectomy along the left recurrent laryngeal nerve (RLN) could be accomplished during esophagectomy under mediastinoscopy. (II) At the level of the lower edge of the right subclavian artery (RSA), between the trachea and the esophagus, instruments are used to access the right RLN. Lymphadenectomy of up to 2 cm could be accomplished at the upper edge of the RSA. (III) Between the trachea and esophagus, the left and right main bronchi are exposed along the trailing edge of the trachea down to the carina, and lymphadenectomy can be performed here. Results This lymphadenectomy had been completed successfully on 117 patients, and 1 was converted to thoracotomy due to intraoperative tracheal membrane damage. The average operation time was 181.4 ± 43.2 minutes, bleeding volume was 106.4 ± 87.9 mL. The number of dissected LNs of upper mediastinal, the left RLN, the right RLN and the subcarinal was 11.2 ± 6.3, 5.1 ± 2.8, 3.2 ± 1.3 and 3.8 ± 2.1 respectively. 10 cases of (8.5%) anastomotic fistula were resolved with proper drainage and nutritional support. There were 25 cases (21.2%) of anastomotic strictures, 10 cases (8.5%) of pleural effusion, 20 cases (16.9%) of hoarseness. The incidence of hoarseness was 2.5% in three months postoperation. Conclusion These results showed that the lymphadenectomy through the left neck approach was not inferior than other surgical approaches in the amount of upper mediastinal LNs resection and perioperative outcome. Further research is needed to discover its impact on the long-term prognosis of ESCC patients.

263 MEDIASTINAL LYMPHADENECTOMY UNDER LAPAROSCOPIC ASSISTED SINGLE-PORT INFLATABLE MEDIASTINOSCOPY THROUGH LEFT NECK APPROACH

Minimally invasive esophagectomy (MIE) has developed for decades. However, conventional MIE requires transthoracic operation, it could increase the risk of many perioperative cardiopulmonary complications. Therefore, mediastinoscopy-assisted transhiatal esophagectomy has been proposed, but the traditional surgical methods have shortcomings, such as unclear vision, especially during the dissection of mediastinal lymph nodes. A new approach of mediastinal lymphadenectomy under single-port inflatable mediastinoscopy through one left-neck incision was proposed. Methods With pneumomediastinum, esophagectomy was to be performed over the aortic arch to the level of lower edge of the left main bronchus, and the lymphadenectomy of 106recL has also accomplished during this process. At the level of lower edge of the right subclavian artery (RSA), between the trachea and the esophagus, the instruments could get accessed to the right RLN. The lymphadenectomy could get accomplished up to 2-cm at the upper edge of the RSA. Between the trachea and esophagus, the lymphadenectomy of 107 would be performed along the trailing edge of the trachea down to the carina. Results 56 patients with esophageal squamous cell carcinoma from March to September 2019 who underwent this operation. The mean age of 56 patients was 67.4 years, 46 were males, and 10 were females. Preoperative TNM staging: T1b, 10 cases; T2, 35 cases; and T3, 11 cases. The median number of mediastinal LNs removed was 17 (9 to 23); 6 (2 to 9) along the left RLN; 3 (1 to 6) along the right RLN. 7 patients (12.5%) developed RLN palsy. All of the 7 RLN palsy were left side, none of them appeared at 3-month postoperation. Conclusion This single-port inflatable mediastinoscopy technology could remove the upper mediastinal LNs on both sides with a single incision on the left neck, avoid trauma to the right neck. The bilateral RLN could be clearly exposed and protected under the mediastinoscopy. Compared with previous surgical techniques, this surgery is less invasive, and the bilateral RLN is more clearly revealed. The surgical procedure described here is the first mediastinal lymphadenectomy under mediastinoscopy through one single left-neck incision. Video https://www.jianguoyun.com/p/DUvIaIsQoPWPBhj1mt8C.

Bilateral Chylothorax Following Left Neck Dissection and Literature Review

BackgroundAlthough chyle leakage may occur in the neck when the thoracic duct is damaged during cervical dissection, it is extremely rare for the chylothorax alone to leak chyle into the thoracic cavity. Case presentationWe report a case of bilateral chylothorax without chyle cervical leakage after left neck dissection, wherein partial left upper jaw resection and left radical neck dissection were performed in a 46-year-old woman who was diagnosed with left upper gingival cancer. The thoracic duct was ligated and cut during surgery and, although no obvious leakage of lymph was observed, dyspnea and cough reflex during deep inhalation were observed from the 3rd postoperative day. Approximately 600 mL of yellowish-white pleural effusion was aspirated during bilateral thoracentesis, and chylothorax was diagnosed based on clinical findings and biochemical analysis results. The patient was put on a low-fat diet on the 4th postoperative day, and a total of 3 neck drains were removed 8 days after the operation. ConclusionsPleural effusion disappeared on imaging examination 16 days after thoracentesis and 5 years and 6 months have passed since the operation. At this time, there has been no evidence of tumor recurrence, metastasis, or pleural effusion.